1. Mosby items and derived items © 2005 by Mosby, Inc. Chapter 31 Vital Signs

2. Mosby items and derived items © 2005 by Mosby, Inc. Guidelines Nurse’s responsibility/delegation Equipment Knowledge of client’s range Knowledge of client’s history and current status Environmental factors Systematic approach

3. Mosby items and derived items © 2005 by Mosby, Inc. Guidelines (cont'd) Approach with the client Frequency of assessment Assessment for medications Analysis and verification of results Communication of results Teaching

4. Mosby items and derived items © 2005 by Mosby, Inc. Temperature Body temperature Physiology –Regulation: neural and vascular control –Heat production Basal metabolic rate Shivering Nonshivering thermogenesis

5. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Physiology –Heat loss Radiation Conduction Convection Evaporation

6. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Physiology –Skin and temperature regulation Behavioral control

7. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Factors affecting temperature –Age –Exercise –Hormone level –Circadian rhythm –Stress –Environment

8. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Temperature alterations –Pyrexia (fever) –Hyperthermia Heatstroke Heat exhaustion –Hypothermia Frostbite

9. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Assessment –Sites –Thermometers

10. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Nursing diagnoses –Risk for imbalanced body temperature –Hyperthermia –Hypothermia –Ineffective thermoregulation

11. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Planning –Goals and outcomes –Setting priorities –Continuity of care

12. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Implementation –Prevention of alterations –Interventions for fever –Interventions for hyperthermia –Interventions for hypothermia

13. Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Evaluation –Changes in body temperature

14. Mosby items and derived items © 2005 by Mosby, Inc. Pulse Physiology and regulation –Stroke volume –Cardiac output –Mechanical, neural, and chemical factors

15. Mosby items and derived items © 2005 by Mosby, Inc. Pulse (cont'd) Assessment –Sites Radial Apical Other peripheral sites –Use of a stethoscope

16. Mosby items and derived items © 2005 by Mosby, Inc. Pulse (cont'd) Character of the pulse –Rate –Rhythm –Strength –Equality

17. Mosby items and derived items © 2005 by Mosby, Inc. Pulse (cont'd) Nursing diagnoses –Activity intolerance –Decreased cardiac output –Ineffective tissue perfusion

18. Mosby items and derived items © 2005 by Mosby, Inc. Respiration Physiological control –Oxygen –Carbon dioxide Mechanics of breathing –Inspiration –Expiration –Tidal volume

19. Mosby items and derived items © 2005 by Mosby, Inc. Respiration (cont'd) Assessment –Rate –Ventilatory depth –Ventilatory rhythm –Arterial oxygen saturation

20. Mosby items and derived items © 2005 by Mosby, Inc. Respiration (cont'd) Nursing diagnoses –Activity intolerance –Ineffective airway clearance –Ineffective breathing pattern –Impaired gas exchange –Ineffective tissue perfusion

21. Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure Physiology –Cardiac output –Peripheral resistance –Blood volume –Viscosity –Elasticity

22. Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure (cont'd) Influencing factors –Age –Stress –Ethnicity –Gender –Diurnal variation –Medications –Other

23. Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure (cont'd) Alterations –Hypertension –Hypotension Orthostatic hypotension

24. Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure (cont'd) Measurement –Equipment Manual and automatic –Auscultation –Palpation –Sites –Children –Self-measurement

25. Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure (cont'd) Nursing diagnoses –Anxiety –Decreased cardiac output –Deficient/Excess fluid volume –Risk for injury –Acute pain –Ineffective tissue perfusion

26. Mosby items and derived items © 2005 by Mosby, Inc. Additional Nursing Interventions Client teaching Reporting and recording